Expanding access to dermatologic care: a retrospective analysis comparing teledermatology and in-person management for lichen sclerosus

What is known about this subject in regard to women and their families? Lichen sclerosus (LS) is a chronic inflammatory skin disorder that disproportionately affects women, with a female-to-male ratio as high as 10:1. LS commonly involves anogenital structures, leading to symptoms such as pruritus, dyspareunia, and micturition difficulties, significantly impacting quality of life. Delays in diagnosis and treatment can lead to disease progression, scarring, and an increased risk of squamous cell carcinoma. Teledermatology (TD) has emerged as an alternative to traditional in-person care, improving access to dermatologic evaluation, particularly for underserved populations. What is new from this article as messages for women and their families? This study provides a comparative analysis of TD versus in-person management of LS, assessing differences in access to care, diagnostic accuracy, treatment, and follow-up compliance. Findings suggest that TD significantly reduces the time to specialist consultation, with asynchronous TD patients receiving expert recommendations within 12 hours, compared with weeks for in-person visits. Female TD patients were significantly younger than in-person female patients, suggesting that younger women may be more inclined to utilize digital health services. Despite differences in access and diagnostic processes, TD and in-person care demonstrated comparable treatment protocols and follow-up adherence, supporting the feasibility of TD in LS management. Background Lichen sclerosus (LS) is an inflammatory dermatologic condition characterized by scaling white plaques, atrophy, and pruritus.1 Due to the frequent involvement of anogenital structures, this condition can cause dyspareunia, micturition, and sexual dysfunction.2 Women are disproportionately impacted, with a reported female-to-male ratio as high as 10:1.3 The COVID-19 pandemic accelerated the adoption of teledermatology (TD), enabling remote diagnosis, treatment, and management of dermatologic conditions. This innovation has expanded access to specialist care, particularly for underserved populations, by reducing wait times, minimizing travel, and offering timely interventions.4 While TD has proven effective for various skin conditions, there remains a gap in the literature regarding its utility for diagnosing and managing LS. To our knowledge, there is only 1 study that has reported on the use of TD platforms in the management of LS, reporting only patient age and consultation frequency.5 Our study aims to assess the impact of TD on patient access to care, diagnosis, treatment, and follow-up compliance of patients diagnosed with LS compared with in-person patients with the same diagnosis. Methods An institutional review board-approved, retrospective analysis of electronic medical records at the University of Pittsburgh Medical Center from January 2020 to June 2024 identified 165 patients with LS. These visits were either new appointments or follow-ups for the chronic disease diagnosis of LS. Of these, 153 (92.7%) were in-person patients, and 12 (7.3%) were TD patients. Of the TD patients, 4 were asynchronous physician-to-physician consults (eConsults), 2 were asynchronous patient-to-physician requests (eVisits), and 6 were synchronous visits (Video). Cases were analyzed for demographics, consult submission-to-response time, diagnostic concordance, treatment protocols, and follow-up compliance. We recorded the location of the disease as reported by the physician in the electronic medical record: the description “groin” includes the area of the inner thighs, while the description “genitals” specifically refers to the penis or vagina/labia. The description “perineum” includes the area between the genitals and rectum. Extragenital sites included locations such as the extremities and the back. Student’s t tests were used for statistical analysis, with a P value of .05 used for significance. To ensure patient safety and privacy, all TD workflows included explicit informed consent for the submission of genital images. Patients were instructed on secure image capture and upload procedures within the Health Insurance Portability and Accountability Act-compliant platform, which restricted access to authorized clinical personnel only. Clear guidance on appropriate framing, avoidance of identifiable facial features, and the option to decline image submission were incorporated to support patient comfort and maintain confidentiality. Results In-person patients had a mean age of 58.5 years, which was significantly higher than the TD cohort’s 49 years (P = .046). Moreover, female TD patients were also significantly younger than in-person female patients (58.3 years vs 49.4 years, P = .0118), as displayed in Table 1. The younger age of TD patients may reflect a demographic preference for digital health services or barriers to accessing in-person care. The average consult submission-to-response time for the 6 asynchronous TD patients was 12 hours and 53 minutes, significantly shorter than the typical wait time of several months for in-person dermatology appointments. Given LS’s potential for long-term morbidity and increased risk of squamous cell carcinoma, the ability to secure specialist input within 12 hours rather than months may have profound implications for disease progression and patient outcomes.1 In terms of site of involvement, both in-person visits (49%) and TD visits (45.5%) were predominantly for genital disease. Among in-person visits, 49% involved genital LS and 18.5% involved extragenital LS. Within the TD arms, synchronous visits included 40% genital and 40% extragenital involvement; TD eVisits involved 100% genital disease; and TD eConsults included 25% genital and 25% extragenital involvement. These findings suggest that synchronous TD visits may have a greater capacity to identify extragenital involvement compared with other TD modalities. In the 4 eConsult cases, there was 0% diagnostic concordance between the consulting physicians and teledermatologists, as shown in Table 1, as primary care providers did not accurately diagnose skin conditions as LS. This finding suggests that primary care providers may benefit from TD consultations to confirm diagnoses before initiating treatment, particularly for complex dermatologic conditions such as LS. Lastly, there were no significant differences between in-person and TD patients regarding treatment protocols, frequency of biopsies, follow-up compliance, or location of the LS. However, potential limitations of TD are the fact that sending digital images of the anogenital area may deter some patients, and it may also be challenging to obtain clear images that also assess scarring and clitoral hood mobility. Table 1 - Descriptive statistics and diagnostic concordance between TD and PCPs Variable In-person (n = 151) Overall teledermatology(n = 12) TD synchronous (n = 6) TD-eVisit (n = 2) TD-eConsult (n = 4) Gender (%) Men: 14.57Women: 85.43 Men: 16Women: 83 Men: 33.3Women: 66.7 Women: 100% 100% Age, y (mean) All: 58.5*Men: 57.36Women: 58.28 All: 46.5Men: 32Women: 49.4* All: 40.16Men: 32Women: 49.4 All: 65.5Men: N/A All: 46.5Men: N/A Race (%) White: 89Black: 7.4Asian: 3.3 White: 83Black: 8.3Asian: 8.3 White: 66.6Black: 16.6Asian: 16.6 White: 100 White: 100 Consult submission-to-response time (mean) - - - 12.53 hours 18.05 hours Sites of involvement (%) Genitals: 49Groin: 26.6Perineum: 15.7Extragenital: 18.5 Genital: 45.5Groin: 9.1Extragenital: 45.5 Groin: 20Genitals: 40Extragenital: 40 Genital: 100 Genital: 25Extragenital: 25 Treatment modified (%) 24 50 50 50 50 Topical corticosteroids as first-line (%) 45 100 100 100 100 Concordance between TD and initial PCP diagnosis (%) - - - 0% Follow-up compliance (%) 57.8 83.33 83.33 100 75 PCP, primary care provider; TD, teledermatology.*P ≤ .05.**P < .01. Conclusion Our study highlights the potential of TD as a valuable tool for providing timely and effective care for patients with LS. By reducing wait times and demonstrating alignment with standard care practices, this research underscores the role of TD in expanding access to dermatologic care. Conflicts of interest None. Funding None. Study approval Reviewed and approved by the institutional review board of the University of Pittsburgh (STUDY22010151). Author contributions TD, and VV: Participated in research design, writing of the manuscript, and approval of the version of the manuscript to be published. SD: Conceived the research, participated in research design and writing of the manuscript, and the approval of the version of the manuscript to be published.